Joint replacements are the #1 expenditure of Medicare. The process of approving these medical devices is flawed according to the Institute of Medicine. It is time for patients' voices to be heard as stakeholders and for public support for increased medical device industry accountability and heightened protections for patients. Post-market registry. Product warranty. Patient/consumer stakeholder equity. Rescind industry pre-emptions/entitlements.

Physicians and nurses must discuss with patients
common opioid side effects such as constipation and sedation, other risks such
as addiction and overdose, and potential long-term risks such as hyperalgesia
and sexual dysfunction.

Short-acting opioids such as Dilaudid (hydromorphone)
and Vicodin (hydrocodone/paracetamol) may be helpful for initial pain relief,
but longer-term dosing can lead to breakthrough pain and withdrawal, and these
agents carry a relatively high abuse potential.

Longer-acting opioid analgesics such as Suboxone
(buprenorphine), methadone, and fentanyl have a much lower abuse liability.
However, methadone is
found in more overdose deaths than any other prescription opioid and
should not be prescribed for opioid-naive patients. Because analgesic effects
of methadone are of shorter duration (6 to 9 hours) than its half-life (36
hours), levels may accumulate, leading to respiratory suppression or cardiac
events.

Patients should be instructed to keep controlled
substances safe in a locked location to prevent use or sale by others.

If a physician intends to prescribe opioids for
chronic pain, a narcotic protocol – medication contract, psychological
evaluation, and urine toxicology – should be considered. Monitoring both urine toxicology
and aberrant
behaviors will detect more opioid abuse than either strategy alone.

A “universal
precautions” approach to minimizing risk includes asking patients
about history of substance abuse, written informed consent, and ongoing
reassessment of the benefits of opioid therapy. Clinicians can thus triage patients
to low-, medium-, and high-risk addiction potential. Treatment agreements
should delineate rules such as having no early refills and requiring urine
toxicology.

For patients who develop opioid addiction,
substitution with buprenorphine or another abuse-deterrent formulation and
adherence monitoring can be implemented.

The medical establishment should develop and use
effective analgesics with lower abuse potential. Current research efforts
to identify better methods to detect patients at heightened risk for developing
addiction should be supported.

All
prescribers of opioids must actively manage pain control while aggressively and
intelligently attempting to prevent opioid abuse.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal
of the American Medical Association. Maria A. Sullivan is an Associate
Professor of Clinical Psychiatry in the Division on Substance Abuse at Columbia
University and the New York State Psychiatric Institute.

Comment by Joleen Chambers (FiDA blog)

So . . . those innocent patients who received prescription
pain medication (e.g. long-term maximum dose hydrocodone) will be side railed
into a "new" medical plan to EVALUATE their
pain/addiction level (eliminate the current prescription). How is this new program customized to a victim of a
failed implanted medical device (FDA MedWatch #5009052)? The cascading damage
of failed device, pharma evasion of untreated serious dry mouth side-effect on
dental health, medical abandonment, insurance abandonment, inaccessible
justice, and now potential coercion into withdrawal or alternate medication so
that the medical community can move on. How is this patient-centered? The
prescribing doctors need to experience this kind of treatment: they have
no concept.